#5280 - 2012 Insp-Final

INSPECTION REPORT ROUTING SHEET

To be attached to all inspection reports in-house only.

Laboratory Cert. #: 5280

Laboratory Name: Taylor Extended Care Facility

Inspection Type: Municipal Maintenance

Inspector Name(s): Todd Crawford

Inspection Date: December 4, 2012

Date Report Completed: December 5, 2012

Date Forwarded to Reviewer: December 5, 2012

Reviewed by: Jason Smith

Date Review Completed: December 6, 2012

Cover Letter to use: Insp. Initial Insp. Reg.
Insp. No Finding Insp. CP
Corrected

Unit Supervisor: Dana Satterwhite

Date Received: December 6, 2012

Date Forwarded to Linda: December 7, 2012

Date Mailed: December 7, 2012

_____________________________________________________________________

On-Site Inspection Report

LABORATORY NAME: Taylor Extended Care Facility

NPDES PERMIT #: NC0047759

ADDRESS: P.O. Box 100
Sea Level, NC 28577

CERTIFICATE #: 5280

DATE OF INSPECTION: December 4, 2012

TYPE OF INSPECTION: Municipal Maintenance

AUDITOR(S): Todd Crawford

LOCAL PERSON(S) CONTACTED: David Collins

I. INTRODUCTION:

This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater
Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A
NCAC 2H .0800 for the analysis of environmental samples.

II. GENERAL COMMENTS:

The facility has all the equipment necessary to perform the analyses. All traceability information is
documented on the benchsheets.

Current quality assurance policies for Field laboratories and approved procedures for the analysis of
the facility’s currently certified parameters were provided at the time of the inspection.

Contracted analyses are performed by Environment 1, Inc. (Certification #10).

III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:

Proficiency Testing

Comment: The laboratory analyzes additional quality control (i.e., known standards) with Proficiency
Testing (PT) samples. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2
document states: Laboratories shall conduct proficiency tests in accordance with their routine testing,
calibration and reporting procedures, unless otherwise specified in the instructions supplied by the PT
provider. They shall not be analyzed with additional quality control or replicated beyond what is routine
for environmental sample analysis. This requirement is a new policy that has been implemented by our
program since the last inspection. Notification of acceptable corrective action (i.e., additional quality
control standards will no longer be analyzed with PTs) was received by email on December 4, 2012. No
further response is necessary for this finding.

Comment: The laboratory was not documenting PT sample analyses in the same manner as
environmental samples. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2.
document states: All PT sample analyses must be recorded in the daily analysis records as for any
environmental sample. This serves as the permanent laboratory record. This requirement is a new
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#5280 Taylor Extended Care Facility

policy that has been implemented by our program since the last inspection. Notification of acceptable
corrective action (i.e., PTs will be documented on the analytical benchsheets) was received by email on
December 4, 2012. No further response is necessary for this finding.

Comment: The laboratory was not documenting the preparation of PT samples. The Proficiency Testing
Requirements, February 20, 2012, Revision 1.2 document states: PT samples received as ampules
must be diluted according to the PT provider’s instructions. The preparation of PT samples must be
documented in a traceable log or other traceable format. The diluted PT sample becomes a routine
environmental sample and is added to a routine sample batch for analysis. This requirement is a new
policy that has been implemented by our program since the last inspection. Notification of acceptable
corrective action (i.e., PT sample preparation will be documented by dating and initialing the PT
preparation instruction sheet and filed with other PT documentation) was received by email on
December 4, 2012. No further response is necessary for this finding.

IV. PAPER TRAIL INVESTIGATION:

The paper trail consisted of comparing field testing records and contract lab reports to Discharge
Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Quality. Data were
reviewed for August, September and October, 2012. No transcription errors were detected. The facility
appears to be doing a good job of accurately transcribing data.

V. CONCLUSIONS:

All findings noted during the inspection were adequately addressed prior to the completion of this
report. The inspector would like to thank the staff for its assistance during the inspection and data review
process. No response is required.

Report prepared by: Todd Crawford Date: December 5, 2012
Report reviewed by: Jason Smith Date: December 6, 2012